Objective: to investigate the effects of fistulojejunostomy in treatment of pancreatic externalfistula. Design and setting: The work was designed as observational studies and the work was devel oped in Department of Hepatobiliary Surgery, Guizhou Provincial People’s Hospital, Guiyang city, Guizhou Provience, China. Methods: Using fistulae-jejunum Roux-en-Y anastomosis to treat 6 pancreatic external fistulapatients who underwent severe acute pancreatitissurgery Results: All patients recovered 4 to 6 days, means 4.9±0.5 days; no one underwent complica-tions. Conclusions: Fistulae-jejunum Roux-en-Y anastomosis is an easy, safe and reliable method to treat pancreatic external fistula, which preserves pancreatic exocrine and endocrine function, the recommending surgery within 3 to 6 months after onset of pancreatic external fistula.
2. Key wordsFistulojejunostomy; Pancreaticexternal fistula; Treatment;Effects
3. IntroductionPancreatic fistula is traditionally classified as internal fistula and external fistula, which is a complication after surgery to treat severe acute pancreatitis, vater peri-ampullary carcinomas, other abdominal disease and abdominal trauma. It is very tricky to treat pancreatic external fistulas, especially to those who undergo severe acute pancreatitis surgery. We used fistulae-jejunum Roux-en-Y anastomosis to treat 6 pancreatic external fistulas patients who underwent severe acute pancreatitis surgery and had good effects, reported below.
4. MethodAll patients with pancreatic external fistulas underwent severe acute pancreatitis surgery for more than 3 months and the drainage fluid collections of each patient were more than 50 mL/day, patients were made a definite diagnosis of pancreatic external fistulas via high amylase levels of clear drainage fluids (>10,000u/L). Patients with pancreatic pseudocysts, pancreatic necrosis, peripancreatic or pancreatic abscess, pancreatic tumor, sepsis, ascites, hemorrhage, pancreatic internal fistula, complicated other digestive fistula and had other surgery indications were excluded from other symptoms or signs of peritonitis were also excluded from the study. According to this criterion, 6 patients were selected from Department of Hepatobiliary Surgery, Guizhou Provincial People’s Hospital from January of 2011 to September of 2016. 2 patients were male and 4 patients were female, aged from 25 to 62 years, means 42.5±6.8 years; Patients underwent severe acute pancreatitis surgery for 3 to 6 months, means 4.6±0.4 months. The drainage fluid collections of each patient were from 100 to 300 mL/day, means 183±25 mL/day. All patients must be evaluated preoperatively and perioperatively including patient’s history, blood tests, abdominal computerized tomography and abdominal ultrasonogram, etc. We found the fistulae at the end of drainage tube and conducted fistulae-jejunum Roux-en-Y anastomosis. We didn’t use any other stent for fistulojejunostomy. And routinely an abdominal drain was placed under the anastomotic stoma at the end of the surgery. The abdominal drain was extracted on the 7th to 9th postoperative day once abdominal was clear (via ultrasonogram).
5. ResultsAll patients recovered 4 to 6 days, means 4.9±0.5 days; no one underwent anastomotic fistula, anastomotic stricture, pancreatic pseudocysts, acute pancreatitis and other complications. All pa- tients werefollowed-up at least 3 months.
6. DiscussionMost pancreatic external fistulas are iatrogenic in etiology. Pene- trating abdominal trauma is a rare non-iatrogenic cause of pan- creaticexternal fistulas. The best strategies for the management ofpancreatic external fistulas is still highly debated especially to thoseundergo severeacute pancreatitis surgery. Many early pancreatic external fistulas patients are likely to respond to conservative ther-apy, such as gastrointestinaldecompression, use of octreotide or somatostatin, nasojejunal feeding, etc. For unresponsive patients, the pancreatic external fistulas may last forweeks, months or years,and other interventions are generally required. Different strategiesinclude both preservation of the pancreatic remnantand a com- pletion pancreatectomy. Completion pancreatectomy avoids fur- ther pancreatic external fistulas but leads to complete pancreaticinsufficiency and “brittle” diabetes [1]. Preserving approach—de- bridement and drainage of the dehiscent pancreatic region is tech-nicallyeasier and preserves remnant pancreatic functions. Internaldrainage by pancreaticogastrostomy or pancreaticojejunostomy issafe and successfulfor treatment of pancreatic external fistulas [2].Drainage of dehiscent pancreatic region followed by gastrofistulo-stomy is also useful to treatpancreatic external fistulas [3]. Reportdemonstrates that only using pancreatic stent for treatment of pan-creatic external fistulasis effective [4].Fistulojejunostomy is usefulto treat pancreatic external fistulas, recommending surgery within 1.5-3 months after onset of a pancreatic fistula[5], whereas othersrecommend waiting for 6 months or 1 year, because part of pan- creatic fistula spontaneously close after the acute episode,an ad- ditional advantage of delayed treatment is optimization of patient nutritional, functional status and development of a robust fistula tractallowing for a more robust target for Roux-en-Y drainage [6,7]. Our group chose fistulae-jejunum Roux-en-Y anastomosis to treat pancreaticexternal fistulas because it was very difficult to find dehiscent pancreatic region and the enormous risk of debridementthe main pancreatic ductand converted to pancreaticogastrosto- my or pancreaticojejunostomy. According to our experience, Fis- tulae-jejunum Roux-en-Y anastomosiswas safe, easy and reliable to perform, which preserved pancreatic exocrine and endocrine function, and the recommending surgery was 3-6months after onset of pancreatic external fistulas, the fistula tract was robust enough to perform Roux-en-Y drainage. Six patients with pancreatic external fistulas after severe acute pancreatitis surgery weresuccessfully closed the pancreatic external fistulas and had no com-plications.On the other hand, whether this operation method will lead to increase risk of fistula stricture, pancreatic pseudocysts andacute pancreatitis inlong time was still need to study. There was a need for much investigation about fistulae-jejunum Roux-en-Y anastomosis to treat pancreaticexternal fistulas after severe acute pancreatitis surgery
7. ConclusionFistulae-jejunum Roux-en-Y anastomosis is an easy, safe and reli-able method to treat pancreatic external fistulas, which preserves pancreatic exocrine and endocrine function, the recommending surgery within 3 to 6 months after onset of pancreatic external fis-tulas.
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Citation:Li KY. Effects of Fistulojejunostomy in Treatment of Pancreatic External Fistula. Annals of Clinical and Medical Case Reports 2020